October 17, 2016

DEEP DIVES | Autopsy: An Underused Resource

ByEmily Hagen | October 17, 2016

The room in which I learned the most this past summer might surprise you. It was not a room in a library, an office, or a classroom filled with books and papers. Rather, it was in a room in a hospital basement connecting to a morgue with human bodies and organ specimens. In this room, I saw two autopsies. An autopsy is a postmortem examination to discover the cause of death or the extent of disease in the deceased individual. Autopsy comes from the Greek words “auto” and “opsis,” literally meaning, “to see for oneself.” I believe the autopsies allowed me to gain a greater understanding of both human anatomy and human pathophysiology in deeper ways than any textbook or lecture could have. I observed the manifestation of certain diseases by noticing the sizes and appearances of organs with my own eyes, as well as holding and feeling the organs with my own hands.

Important Uses of the Autopsy

Much of today’s medical knowledge was gained from the findings from autopsies. Our understanding of the major diseases, including cancer, cardiovascular disease, atherosclerosis (which is the build-up of fats, cholesterol and other substances in and on the artery walls), as well as inflammatory disorders, infectious disease, among others, was aided by autopsy findings.

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According to an article in STAT, “rapid autopsies” — autopsies conducted within a few hours of a patient’s death — could expedite cancer research. For instance, the findings of a rapid autopsy performed on a patient with breast cancer at Johns Hopkins hospital led to the discovery of an experimental drug that targets both the mutant gene responsible for the initial tumor and the genetic counterparts responsible for the metastases.

According to a New York Times article by Dr. Sandeep Jauhar, a cardiovascular disease doctor affiliated with Glen Cove Hospital and Northwell Health Long Island Jewish Medical Center, although modern testing can provide us a great deal of information about the cause of a person’s death, 10 to 30 percent of autopsies expose undiagnosed medical problems. He explained that studies have showed that doctors at hospitals that perform more autopsies commit fewer substantial diagnostic mistakes. Also, post-mortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths, according to a report called “Improving Diagnosis in Health Care” issued in 2015 by the National Academy of Sciences.

Moreover, according to a review study published in The Journal of the American Medical Association in 2015 about autopsy-detected diagnostic errors, autopsy studies have revealed significant discrepancies between clinical diagnoses and autopsy diagnoses, with important implications in terms of clinical care. For example, major diagnostic errors detected by autopsies most likely led to treatment errors in addition to inaccuracies in death certificates and hospital discharge data. This has large ramifications since epidemiologic research and healthcare policy decisions are influenced by these data.

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The review study was conducted by Kaveh G. Shojania, MD and Lee Goldman, MD-MPH of the University of California, department of medicine, Elizabeth C. Burton, MD of the Baylor Health Care System, Dallas-Fort Worth, Texas, San Fransisco, and Kathryn M. McDonald, MM of Center for Primary Care and Outcomes Research, Stanford University.

Furthermore, the autopsy is vital for the sake of public health efforts that inform people’s everyday habits. As the many Cornell students who have taken HD 3460: Human Bonding know, the American Academy of Pediatricians in 1992 recommended that parents must not put their infants to sleep on their stomachs or surround them with potentially harmful items, such as blankets and dolls.

These recommendations were based on data from autopsies illuminating the connection between babies’ sleeping positions and their risk of dying from Sudden Infant Death Syndrome. The “Back to Sleep” movement of the 1994 was launched by the US National Institute of Child Health and Human Development to spread the word to parents that it is safer for babies to be put to sleep on their backs, or supine position.

“Whenever a healthy baby suddenly dies we want to know why. The discovery that the cause might simply be the position in which that baby was placed to sleep in the crib — face up or down — was a major advance. And it is an advance that was made possible by autopsy,” said Prof. Cindy Hazan, human development, who teaches the class Human Bonding.

The benefits related to autopsies are not limited to the realm of medicine and health-related knowledge. Autopsies can also provide valuable information to the family members of those who passed away. According to an article in the Wall Street Journal, by Melinda Beck, the writer of the weekly Health Journal column in the Wall Street Journal, a 2008 study that examined 54 sudden deaths outside hospitals that were attributed to coronary artery disease found that other heart issues in fact caused half of these deaths.

This study demonstrates that it is important that the family members of decedents learn the details of how their loved ones died because this knowledge could serve to benefit the family members’ health and well-being. In this case, the family members of the decedents could learn if their loved ones died of inheritable heart problems or conditions that are more related to lifestyle and diet. As a result, the family members could be more informed about their own lifestyle choices and if and when they should see a cardiologist.

Autopsies that elucidate information about Alzheimer’s disease can similarly be very useful to family members of those who passed away from the disease.

“Typically for brain and nerve degeneration diseases, we don’t have access to tissue until an autopsy. The autopsy is critically important for the realm of any disease process for which you never obtain pre-mortem tissue. The epitome of that is neurodegenerative diseases, where you can’t do a biopsy to diagnose Alzheimer’s disease. So, you need post-mortem tissue to learn about the disease from a tissue standpoint,” said Dr. David Pisapia, assistant professor of pathology and laboratory medicine at Weill Cornell Medical College, autopsy pathologist, and neuropathologist.

The benefits associated with performing an autopsy are clearly many, for both medical professionals and the general public.

The Problem

Fifty years ago, about half of the patients who died in U.S. hospitals underwent autopsies. Now, however, the fraction of performed autopsies has decreased to less than 10 percent, with almost none in nonacademic hospitals, according to Jauhar.

There are several suggested explanations for the declining rates of autopsies performed in the United States. I believe the main one is that insurance companies, including Medicare, stopped paying for autopsies. Before 1970, the Joint Commission on Accreditation of Hospitals mandated a 25 percent autopsy rate for teaching institutions and a 20 percent rate for nonteaching institutions. Jauhar explained that in 1971, the Joint Commission on Accreditation of Hospitals stopped requiring hospitals to perform autopsies in part because hospitals were unselectively using autopsies to meet target rates without using the resulting information that was intended to evaluate and ameliorate hospital care.

In 1986, Medicare, perhaps skeptical of the utility of autopsies, stopped paying for them directly. Since then, managed care organizations and third-party insurers have stopped covering autopsies as well. Consequently, for an autopsy to be performed when one’s insurance will not cover it means that the family members of the descendants must pay for private autopsies, and at a high cost ranging between $3,000 and $5,000, according to the website for the College of American Pathologists.

I believe that the lack of reimbursement conveys to the profession that being a pathologist is no longer valued, either professionally or financially. As Jauhar explained, many doctors today believe that medical tests will explain all they need to know about how and why a patient died. This is not the case, however, because diagnostic errors remain widespread, even with recent technological advances. Autopsies can serve as a solution.

“By doing routine autopsies, much was learned about the prevalence of diseases, the early (preclinical) manifestations of such problems, and so on. But then imaging modalities improved, and then Medicare stopped paying for autopsies, and autopsies were no longer done except in forensic cases. A real loss. For example, I’m sure we still miss many cases of pulmonary emboli, a good many of which are fatal but simply attributed to other causes such as congestive heart failure,” said Dr. Leonard Grauer, associate clinical professor of medicine at Yale University School of Medicine. (A pulmonary embolism is a condition in which one or more arteries or arterial branches in the lungs become blocked by a blood clot).

Another factor contributing to the decline in autopsy rates is the development of sophisticated medical technologies that can be used to understand a patient’s health condition or disease while the patient is alive, which is a notion that has shaped doctors’ conception of the autopsy.

“The amount of testing pre-mortem has exponentially increased. So, a lot of doctors having the feeling that there cannot be many questions left unanswered because they used medical technologies, such as sophisticated MRI. They wonder what an autopsy will tell them,” Pisapia said.

I believe there are even more factors contributing to the overlooked and underused nature of the autopsy. One is doctors’ lack of familiarity with the autopsy procedure. Geoffrey A. Talmon, MD of the University of Nebraska Medical Center, Donna Czarnecki of the Dent Neurologic Institute, and Dr. Kerry Bernal, an anatomic and clinical pathologist at a medical center in Nebraska, wrote a paper in the American Journal of Clinical Pathology in 2014, explaining that a reason for declining autopsy rates is that many doctors may not have had adequate exposure to autopsies during their training.

Providing medical students with the opportunity to attend autopsies has been a proposed solution to this challenge. However, the lack of autopsies available for students to observe makes attending autopsies difficult. Dr. Talmon wrote in a separate article published in the National Center for Biotechnology Information in 2010 that fewer than half of U.S. medical school graduates have seen an autopsy while in medical school.

“I think the importance of the autopsy is known by medical students, but it is pushed to the side by the other subjects within our core curriculum. Many students know of the contributions that the autopsy has provided us, but almost none of us have ever participated in an autopsy. We would be much better served as clinicians, if we were able to be a part of the autopsy, and possibly do research surrounding the autopsy,” he said.

Furthermore, Talmon found that only 41 percent of the medical schools he surveyed require students to observe autopsies, and most medical school students do not view an autopsy voluntarily.

“Currently in medical school, there have been no formal sessions about how to perform an autopsy, or when the autopsies occur. The only way to see an autopsy currently is to find a pathologist, and ask to shadow,” Husain said.

Another major source of the problem is that there is a scarcity of trained medical examiners, or forensic pathologists. A report from the Scientific Working Group for Medicolegal Death Investigation stated that there are about only 500 full-time forensic pathologists, which is half as many as deemed necessary to provide adequate coverage for the U.S.

There are more than 130 medical schools in 45 states and in D.C., but only 37 accredited forensic pathology training programs across twenty-seven states and Puerto Rico. It is also important to note the report’s explanation that of the few doctors who pursue forensic pathology fellowships, only two-thirds of them practice full-time due to challenging cases with media exposure and lower pay than other medical specialties. Also, the issue of physician burnout applies to pathologists to a great extent.

An additional underlying issue that could be contributing to the marked decline in autopsy rates could be doctors’ fear of medical malpractice. Many doctors might fear that a diagnostic or treatment errors of theirs might be found through an autopsy, which could possibly lead to a lawsuit given the current litigious atmosphere permeating our society.

The responsibility of pathologists, though, is to figure out why patients died, and not to cover up malpractice. Therefore, another important use of the autopsy is that family members of their deceased loved ones can gain solace and comfort in knowing what happened to their loved one, and also, what it may mean for their own lives moving forward.

Proposed Solutions

I believe that the declining rate of autopsies and overlooked nature of the autopsy is too severe a problem for there not to be multiple solutions considered. There is a variety of possible solutions that could help to address the issue of the declining rate of performed autopsies, and they occur at different levels.

The problem must be addressed from a financial perspective. Specifically, Medicare and other insurers must cover the cost of the autopsy. However, the only way that insurance companies will cover the cost of autopsies again is if they recognize the financial value of advancing medical knowledge and improving the health of people on both individual and public levels. Furthermore, forensic pathologists’ salaries must become more competitive in an effort to attract more medical students to the specialty.

A way that could emphasize the utility of the autopsy is through the implementation of substantial education and outreach efforts. Overall, there needs to be greater understanding of the positive effects autopsies can have and spanning different domains — including for the advancement of scientific and medical knowledge that informs patient care and public health efforts, as well as for the benefit of decedents’ families health and emotional well-being.

I also believe that medical school students should have more opportunities to explore the field of pathology and view autopsies. According to Pisapia, a recently implemented initiative at Weill Cornell Medical School is a pathology interest group, enabling medical school students to learn more about pathology through microscopy discussions and talks given by pathologists. Such an effort, even initially on a small-scale level, should serve as a model for other medical schools as part of the solution to the current lack of education about pathology and the autopsy in medical school education.

To foster a more profound appreciation for the worth of the autopsy, the public must understand that the medical knowledge that we have today, and are continuing to discover, is largely through autopsies and that further increases in medical knowledge would be more likely to continue if autopsies were to be performed more regularly again.

In working to educate the public about the utility of the autopsy, the misconceptions that some people hold about the autopsy must be addressed.

“I think just misinformation and the negative public image of autopsies have driven the rates down drastically. Perhaps busting myths and emphasizing the public health implications from autopsies can drive the rates back up,” said Sam Yim ‘17, a pre-medical student.

Pisapia feels similarly, and believes that people confuse the medical autopsy, which is a professional and surgical procedure, with forensic examinations.

“From the media, TV, etc., most people think of autopsies as forensics and medical exam and bones and crime scenes, and they don’t really have a conception of the medical autopsy. The other barrier is that people do not understand the procedure itself. I think there needs to be an understanding that we are all professionals,” Pisapia said.

In addition to these communication efforts with the public, I think there also needs to be more communication efforts on the part of pathologists. Pisapia agrees.

“In terms of communication between pathologists and clinicians, I think there a number of things pathologists could do market the value of the autopsy to a clinician. In my opinion, one of the advantages of autopsy today is that we have lots of technology to study pathogenesis that we didn’t back then. Today, we can take all the metastases, sequence them, see how tumor evolved over time, and look at mutational differences to understand metastases. If you have unusual bacteria that killed a patient, you can sequence the bacteria and see drug resistance. There is much more information we can get from autopsy findings that we couldn’t get in the past,” Pisapia said.

Pathologists should emphasize to other physicians the importance of the autopsy as an option to be routinely presented to the family members of their patients when they pass away as part of end-of-life-care. I realize that these conversations would be quite arduous to initiate. However, the positive features of the autopsy could be stressed, where the physician explains what the autopsy could offer to the family, whether it is medical information that could help them or comfort in knowing the science behind their family member’s death, while the physician addresses any of the family members’ concerns.

In Summary

This summer, I saw for myself many things that can be uncovered and discovered through an autopsy, as autopsy indeed means “to see for oneself.” I realized the many people can benefit from the findings of autopsies, including doctors, scientists, students, the general public, policymakers, and family members. Therefore, I now am, and will continue to be, inspired to help make the important and overlooked nature of autopsies known to others. Members of the medical community and the public need to see for themselves the utility of the autopsy, and to strive to bring it to the forefront of medicine.

ByElyes Benatar, Zachary Lee and David GouldthorpeNovember 16, 2016

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